Grievance Form

Grievance Form

Form can be completed by staff, resident, or family member
Resident Name or Other Party Name

First NameLast Name
Room Number
Position / Relationship (if not resident)
Today’s Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Discovery of Occurrence

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Person Expressing This Grievance

First NameLast Name
Relationship to Resident or Other Party
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Grievance Classification and Submission Details
Discriminatory Claim Basis
Grievance Category

Other
Other Grievance Category
Grievance Submission

Other
Statement of Concern
Intake, Forwarding, and Resolution Tracking
Name & Title of Employee Accepting This Form
Date Accepting This Form

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Steps Taken to Resolution
Grievance Recorded on Grievance Log
Decision/Investigation Outcome Discussed with Person Filing Grievance
Employee Responsible
Date Outcome Discussed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grievance Resolved / No Further Action to Be Taken
OR
Unable to Resolve
Section 504 / Section 1557 Grievance
Written Notification Delivered By
Date Notification of Decision Mailed/Delivered

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Medicare participants may submit a written complaint with the Medicare Beneficiary and Family Centered Care Quality Improvement Organization (QIO) regarding Medicare covered services and quality of care issues by contacting any of the following for further assistance:
• 1-800-MEDICARE (1-877-633-4227)
• TTY: l-877-486-2048
• Website: Medicare.gov/claims-appeals/how-to-file-a-complaint-grievance
Should be Empty:

Grievance Form

Grievance Classification and Submission Details

Intake, Forwarding, and Resolution Tracking